ESBD_520882_1779973946774_Attachment 05-VR2897 Orientation and Mobility Referral.pdf
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- Solicitation number
- 3202600155
- Issued by
- Texas
About this file
This document is an Orientation and Mobility (O&M) Referral Form used by the Texas Workforce Commission's Vocational Rehabilitation Services division and the Independent Living Services for Older Individuals who are Blind (ILS-OIB) program. The form serves as a referral mechanism for customers requiring orientation and mobility services, capturing essential customer information including name, date of birth, primary language, contact details, and relevant travel concerns. The referral identifies specific O&M service goals that may apply to the customer, including guided techniques, home and community orientation, cane skills development, stair negotiation, dog guide training and use, and travel preparation for both familiar and unfamiliar areas across residential, business, and paratransit contexts.
The form requires documentation of circumstances that may impact service delivery, including visual diagnosis, secondary disabilities (with specific notation for deaf-blindness communication methods), education level, health issues, safety concerns, and detailed visual acuity measurements. The document functions as an intake and assessment tool that enables VR counselors and IL/OIB workers to systematically communicate referral information to O&M providers, ensuring comprehensive evaluation and tailored service planning for individuals with visual impairments seeking to develop independence in mobility and orientation.
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Text version
VR2897 (10/17) O&M Referral Page 1 of 2
Texas Workforce Commission
Vocational Rehabilitation Services
Orientation and Mobility (O&M) Referral
Customer Information (required)
VR Counselor or Independent Living Services for Older Individuals who are Blind (ILS-OIB) worker name:
Caseload Number:
Office Number:
O&M Provider:
Date of Referral:
Customer Name:
DOB:
Primary Language:
Customer Address:
City:
State:
ZIP Code:
Telephone Number:
Alternate Contact:
Best Day(s) to Contact (if known):
Customer’s and/or VR Counselor or IL/OIB worker travel concerns:
Reason for Request (required)
O&M Goal(s) of the Customer: check box(s) below that may apply
Guided technique(s)
Evaluation purposes only
Orientation to home
Orientation to surrounding community
Basic indoor cane skills
Residential travel
Semi-business travel
Negotiate stairs
Orientation Skills with dog guide
Use of Para transit
Business travel
Dog guide information
Travel in familiar areas
Travel to unfamiliar areas
Unsure if O&M Skills are needed
Other O&M goals (please describe)
Circumstances that May Impact Services (required)
Visual Diagnosis:
Secondary Disability:
If secondary disability is deaf blindness, what is the customer’s primary form of communication?
SAMPLE
VR2897 (10/17) O&M Referral Page 1 of 2
Helpful Information (complete if known)
Level of Education:
Known Health Issues/ Safety Concerns:
Visual Acuity:
OD:
OS:
Visual Fields:
Additional Information:
SAMPLE
File details come from the government source that posted it. Updated .